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St. Mary's Clearwater Valley Hospital and Clinics

Patient Pre-registration Application

This form is to register for our Patient Pre-registration Program. By registering with us you can receive peace of mind that we have your medical information.
Please Print clearly and Complete the following information. This form should take about 5 minutes to complete.
* Today's Date
* Primary Physician
* Patient Full Name
First Name, Middle Initial, Last Name
* Date of Birth
* Street Address
Full Street Address or P.O. Box
* City
* County
* State
* Zip Code
* Telephone
Area Code and 7 Digit Number
* Social Security Number
Nine Digit Social Security Number
* Marital Status Single     Married     Divorced    
* Sex Male     Female    
* Race Black     White     Asian     Indian    
* Language
* Religion
* Are You Employed? Yes     No    
  Employer's Name
If you are employed please list your major employer's business name.
  Employer's Street Address
  City
  State
  Zip Code
Five Digit Zip Code
  Employer Phone Number
Area Code Plus 7 Digit Number
  Type of Position Full Time     Part Time    
  Occupation
  Retirement Date
Fill In This Field Only If You Expect To Retire.
* When Paying Healthcare Bills...How Do You Plan To Pay? Insurance     Cash     Medicaid     Medicare    
  Guarantor/Responsible Party Information (other than self)
**Fill Out Below If The Patient Is Not The Resonsible Party
If Patient Above Is Responsible Party Then Check This Box
  Person Responsible For Bill
  Date of Birth
  Street Address or P.O. Box
  City
  State
  Zip Code
Five Digit Zip Code
  Telephone
Area Code and 7 Digit Number
  Sex Male     Female    
  Relationship To Patient
  Social Security Number
Nine Digit Social Security Number
  Employer's Name
If you are employed please list your major employer's business name.
  Employer's Street Address
  City
  State
  Zip
Five Digit Zip Code
  Employer Phone Number
Area Code Plus 7 Digit Number
  Type of Position Full Time     Part Time    
  Responsible Party's Occupation
* Person To Notify In Case Of An Emergency
Please Type In Full Name, Relationship, Address, Area Code & Telephone Number
  Insurance or Medicare/Medicaid Numbers
Please Include Your Primary and Secondary Insurance Numbers or Medicare and Medicaid Numbers. We Need Your Basic Health Insurance Information. Make Sure You Include Your Group Number or Medicare Number. Please Also List Your Effective Date of Coverage.